Triangle DISABILITY AWARENESS COUNCIL APPLICATION

This application requests some general information based on your interest in applying for a position of the Board of Directors or a position with the Disability Awareness Council.
Membership fee:
$15.00 (disabled)
$25.00 Professional (non disabled)
$150 group

First Name *

Last Name *

Date of Application

Email

Street Address

City

State

Zip

Country

Home Phone

Mobile Phone

Fax Number

Current Employment *

Education, training, skills that qualify you for Board membership or position with OCDAC

List employment or volunteer experience you feel qualifies you for Board membership or a position with OCDAC:

Please indicate your preferences by number (first choice being “1”) and choose no more than three:

Internship EMPLOYMENT Board of OCDAC Programs Committee Publicity Committee Finance and Development Committee Community ACCESS Committee Membership & Outreach Committee Volunteer to work in office or special events

I am applying FOR BOARD:

Appointment Volunteer Only Committees

Please provide a brief statement outlining why you wish to serve on the Advisory Board, or Committees you have indicated.

Orange County Disability Awareness Council Ethics Guidelines

Yes, if appointed, I pledge that I have read and understand and agree to comply with the attached mission statement and code of conduct of Orange County Disability Awareness Council and with any revisions to the statement or code of conduct adopted by the OCDAC Board of Directors.

Confidential Information

In order to consider this application and to protect OCDAC from any possible legal problems, this personal information is required:
NOTE: This information will not be included with the rest of the application for review by the Board. This information will be confidential and reviewed only by legal counsel or another designated person and only will be reported to the Executive Committee of the Board by legal counsel on a need to know and in as limited a factual manner as is possible)

Name

Any other names you have used in the last 10 years:

Date of Birth *

SSA / Driver's License No.

Within the past ten years have you ever been a convicted of any felony?

If yes, please explain:

Within the past ten years have you been investigated by a governmental agency or been the defendant in a lawsuit involving allegation of embezzlement, fraud, theft, dishonesty, abuse of another person, sexual, racial or disability harassment?

If yes, please explain:

Have you been hospitalized or received treatment for drug or alcohol abuse or as part of an involuntary mental commitment?

If yes, please explain:

Certification

I affirm that the above stated confidential information is true to the best of knowledge and agree that if I have purposely not provided truthful information above the Executive Board of the Council has authority to remove me from the Board or any other position I have with the Orange County Disability Council.